Laminectomy Case Summary

MRI of the lumbar spine obtained on 05/19/15 revealed at L2-3, endplate osteophyte formation and disc bulge contribute to a mild degree of spinal canal stenosis and a mild degree of bilateral neural foraminal compromise. At L3-4, a disc bulge eccentric leftward and endplate osteophytes formation are responsible for a mild degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a moderate degree of left neural foraminal encroachment. At L4-5, there is a diffuse disc bulge and endplate osteophyte formation which effaces the ventral aspects of the thecal sac and are responsible for a moderate-to-severe degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a severe degree of left neural foraminal encroachment. At L5-S1, a shallow disc bulge and endplate osteophyte formation contribute to a mild degree of left neural foraminal encroachment, without compromise of the spinal

MRI of the lumbar spine performed on 10/30/14 demonstrated mild anterolisthesis and prominent degenerative changes at L4-5, resulting in contact and possible impingement upon passing L5 nerve roots bilaterally. There is moderate bilateral facet arthropathy at this level. Mild central canal narrowing is seen at L4-5. Mild chronic compression deformity, superior endplate of T12 is seen.

CT scan of the cervical spine dated 01/07/14 revealed posterior fusion from C5 through C7. There is minimal anterior subluxation of C6 on C7.

Patient was encouraged to continue with heat, followed by his home exercise program and ice. He will continue with his transcutaneous electrical nerve unit (TENS). Patient was given an ice pack to use, to reduce pain. He was given a 60 mg Toradol injection on this visit.

MRI of the lumbar spine obtained on 12/21/11 showed at L4-5 level, there is some mild loss of normal hydration of this nucleus pulposus representing early dessication changes, with a minor 2-3 mm subligamentous posterior disk bulge/protrusion slightly elevating the posterior longitudinal ligament indenting the thecal sac without spinal stenosis and neuroforaminal narrowing.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

11/13/14 MRI of the lumbar spine showed 4mm left paracentral and foraminal disc protrusion at L4-5, which mildly impinges upon the thecal sac and the proximal left L5 nerve root. The disc protrusion also moderately narrows the left foramen and lateral recess. There was also a 2mm posterior central disc protrusion at L5-S1. A 2mm disc bulge at L2-3 was seen. There was a mild degenerative facet and ligament flava hypertrophy at L4-5 and

The patient has a history of discectomy to the left with temporary improvement of his lumbar pain and lower extremity symptoms. He has reherniation to the left correlating to the L4-L5. He has had transforaminal epidural steroid injections and facet injections with relief of his lumbar pain.

MRI of the cervical spine dated 03/09/2016 reveals a multilevel cervical spine degenerative disc changes, most pronounced at C4 to C5, C4 to C5 diffuse disc bulge with central protrusion causing moderate spinal canal narrowing, increased fluid weighted signal in the paravertebral soft tissues posterior to the left C3 to C4 lamina and minimally increased fluid weighed signal in the left C3 to C4 lamina and the right facet joint, C4 to C5 right facet joint bone spur.

Per operative reports, the patient is status post lumbar ESI at L4-S1 on 09/11/15 and epidural-based steroid therapeutic pain management at the bilateral L3-4, L4-5 and L5-S1 levels on 10/26/15.

Treatment plan includes follow up evaluation in 6 weeks, follow-up visits and right ESI at L4-5 level as the patient has persistent subjective complaints suggestive of radiculopathy. The epidural injection is required because of spinal surgery recommendations.

Per previous reviews, there was a previous denial for 1 Lumbar Epidural Steroid Injection at Left L5-S1 Level last 07/11/16. Attached is the peer report for additional reference (Review 267045).

The duration of analgesia ranges from 1-12 months. 3 Epidural steroid injections are the most commonly used procedure. It can be administered primarily by three approaches: transforaminal, interlaminar, or caudally to alleviate radicular pain. A recent meta-analysis study found that one third to one half of patients can avoid spine surgery in short term with epidural steroid injection. 11 On the other hand, repeated surgery for epidural scar had only a 30%–35% success rate.

DOI: 7/22/2015. Patient is a 43-year-old female crew member who sustained injury while putting away a cheese machine when she felt low back pain. Per OMNI, she had a lumbar strain. Per operative report dated 11/18/15, the patient underwent a fluoroscopically guided caudal epidural steroid injection.

The image that required the repeat for the LPO lumbar image had several factors that would have prevented a radiologist from interpreting and diagnosing the image accurately. The less than optimal diagnostic value of the image was due to the several errors which positioning was the number one factor for the repeat. Every one of the factors played apart in the reason for the repeat. If the patient was properly positioned in a 45-degree oblique and was anatomically aligned over the center AEC detector cell allowing the cell to be properly exposed, the positioning error which was over rotation of the patient with the evidence of the zygapophyseal joint spaces being closed, the superior and inferior articular processes not in profile, and the